Download Auckland City Hospital Trauma Guidelines

Auckland City Hospital
Trauma Guidelines
June 2016
Auckland City Hospital Trauma Team Guidelines | June 2016
Contents
Introduction .....................................................................................................................................1
Part 1: Trauma Calls ......................................................................................................................2
A. Criteria for a trauma call........................................................................................................ 2
B. Activitating a Code Crimson Call.......................................................................................... 2
C.Initiating a Trauma Team Call................................................................................................ 3
D. Process of care for a trauma call patient.............................................................................. 3
E.Trauma Team Membership and Roles................................................................................... 3
F.Standard precautions............................................................................................................. 6
G. Primary Survey (ABCDE)...................................................................................................... 6
H. Secondary survey................................................................................................................. 8
Part 2: Injury treatment ...............................................................................................................11
Part 3: Algorithms .......................................................................................................................16
Trauma Code Crimson............................................................................................................ 16
Traumatic Cardiac Arrest........................................................................................................ 17
Management of the head injured patient................................................................................ 18
Management of the cervical spine in trauma.......................................................................... 19
Indications for CT Angiogram.................................................................................................. 20
Management of chest trauma.................................................................................................. 21
Management of patient with chest wall trauma....................................................................... 22
Abdominal evaluation in the blunt trauma patient................................................................... 23
Management of penetrating lower chest or abdominal stab wound....................................... 24
Management of fractured pelvis in the trauma patient............................................................ 25
Part 4: Northern region inter-hospital transfer guidelines.......................................................26
Appendices....................................................................................................................................32
Appendix A: Ambulance Triage Codes.................................................................................. 32
Appendix B: Techniques; FAST, DA, DPL............................................................................. 33
Appendix C: Auckland City Hospital Major Trauma Form...................................................... 34
Introduction
These guidelines have been developed following extensive consultation and review. They are
endorsed by the Auckland City Hospital Trauma Service in collaboration with other services.
The treatment of severe trauma is ‘time critical’. Timely and appropriate intervention reduces
preventable levels of mortality, complications and lifelong disability amongst people who sustain a
major trauma.
The initial assessment of a trauma patient is a team process. Most patients with major trauma require
the input of a number of different specialty groups. Often this does not extend outside the trauma
team however the input of orthopaedic, neurosurgical, maxillofacial or plastic surgical teams may be
required. Notify specialists early about severely injured patients
Multiple major trauma patients at the same time are common and can place considerable stress on
the system. This can lead to situations where patients who have severe but not immediately obvious
injures are overlooked. When this situation arises assistance should be summoned early.
The intent of these guidelines is to provide clear consistent guidelines around the process of care and
treatment for trauma patients. It is expected these guidelines will be followed by all staff. Variation
from these guidelines are made only after careful consideration.
These guidelines are in four parts.
•
Part one explains the trauma call process.
•
Part two outlines they standard approach for treatment of injuries
•
Part three has the algorithms for treatment of common injuries
•
Part four has the northern region inter-hospital transfer guideline that indicate which patients should stay at
Auckland City Hospital, and which should be transferred to Middlemore. They also identify specific conditions
which indicate transfer into Auckland from regional referral centres.
Auckland City Hospital (ACH) is the regional tertiary referral hospital for the care of the severely
injured adults.
ACH receives patients with a wide range of injuries, both directly from the scene and following
transfer from other hospitals. ACH provides definitive care for these injuries.
Delays to definitive care increase morbidity and mortality.
ACH has a Trauma Team system which provides immediate skilled emergency care for trauma
patients in the Department of Emergency Medicine and facilitates early progress to definitive care.
These guidelines describe the approach to major trauma patients.
Read and know them before you take on a role within the trauma team.
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Auckland City Hospital Trauma Team Guidelines | June 2016
Part 1: Trauma Calls
A. Criteria for a trauma call
A mandatory trauma call will be made when there is one
or more of:
1. RT call
The emergency department is notified of the imminent arrival
of an unstable patient (Status 1 or 2, see appendix for
ambulance condition status codes)
2. Physiology
•
Respiratory rate < 10 or > 29
•
Systolic blood pressure < 90 mmHg for patients under 55
OR <110 mmHg for patients over 55
•
Heart Rate > 120 bpm
•
Glasgow Coma Scale < 13
These physiological parameters may be met in the ambulance, noted at triage or deteriorated to in the emergency
department.
3. Injury Pattern
•
Penetrating injury to the head, neck or torso
•
Flail chest
•
Complex pelvic injury
•
Two or more proximal long bone fractures
•
Traumatic amputation proximal to knee or elbow
•
Major crush injury
•
Penetrating trauma to a limb with arterial injury
•
Crushed, mangled, amputated or pulseless limb
•
Paraplegia or quadriplegia
•
Major burns
A discretionary trauma call can be made by the Emergency
Medicine registrar or consultant. This may be made for mechanism, physiology, co-morbidities or a combination of these.
These might include:
Major trauma patient transferred from another hospital to the
Emergency Department
5. Multiple Casualties
When the Emergency Department is forewarned of the
imminent simultaneous arrival of four or more trauma
patients, irrespective of their suspected injury severity.
B. Activitating a
Code Crimson Call
A Code Crimson call is made either by HEMS or once the
patient is in ED and assessed as potentially requiring
surgical or interventional radiology to control haemorrhage
post trauma.
Assessment is based on the four parameters of the Assessment of Blood Consumption score (ABC):
1.
Penetrating truncal mechanism of injury
2.
Systolic Blood pressure of 90mmHg or less
3.
Pulse of 120/ min or more
4.
Positive trauma E-FAST ultrasound scan
You score one point for each parameter met. If the patient
scores ≥ 2 points they meet the criteria for Code Crimson
activation.
Code Crimson activation will be sent via Switch to all the
personnel on the standard Trauma Call activation as well as
the following personnel:
1.
Surgical Consultant on call
2.
Emergency Department Consultant if they are not in the
ED
3.
Level 8 Anesthetist
4.
Level 8 Nursing coordinator
5.
Radiology registrar who will contact the on call Interventional Radiologist
Blood bank
•
Fall > 3 metres
6.
•
Entrapment > 30 minute
•
Cyclist or motorcyclist versus car
•
Beta-blockers
The aim of the Code Crimson activation is to get all the
surgical decision makers and facilitators in the resuscitation
room to facilitate rapid access to theatre or interventional
radiology 24 hours a day, 7 days a week.
•
Pedestrian versus car or train
•
Relative hypotension
See Part 3 for the Code Crimson algorithm.
•
Ejection from a vehicle
•
Anti coagulation
•
Fatality in the vehicle
•
Elderly patient with moderate trauma
A trauma call ends with acceptance to a hospital service
(DCCM, a surgical service or the Emergency Department)
with a clear plan for definitive care.
2
4. Transfer
C.Initiating a Trauma Team Call
The trauma call may be initiated at any time: from the receiving of an RT call to definitive care as may otherwise have
been arranged. The trauma call and response is designed to
decrease time to definitive care, when there is the potential
for delays to worsen outcomes.
The nurse co-ordinator dials 777 and requests a trauma call
to the adult ED in xx number of minutes. The trauma team
will not be activated by any other mechanism. There are no
partial calls.
The telephone operator initiates the trauma team group
page and then will log the call from the Emergency Department.
It is the responsibility of all members of the trauma team
to respond immediately to the call. Delegate to an individual of equal or greater seniority when attendance is not
possible. It is the on-call general surgical registrar’s responsibility to ensure a representative from one of the surgical
services attends every trauma call. If unavailable, the general surgical registrar should first nominate the orthopaedic
registrar, next the neurosurgical registrar, next the urology
registrar. At night, when neurosurgical and urology registrars
are not in the hospital, call the paediatric surgical registrar.
Early involvement of the Acute Surgeon/Trauma Consultant
on duty as indicated
D. Process of care for a trauma
call patient
The principles of the EMST course form the basis of these
guidelines. Adaptations to the local ‘environment’ are included.
The process of care for trauma call patients is:
Ambulance hand-over
45 seconds
One person talking, everyone
listening
Describes: mechanism and
time of injury, injuries noted,
signs at the scene, interventions and the response to
intervention. (M.I.S.T.)
Primary Survey
ABCDE
Resuscitation
Immediate therapy for life
threatening injuries and physiological abnormalities detected
in the Primary Survey
Adjuncts to 1o Survey
Monitoring and x-rays, FAST
Secondary Survey
A thorough “top to toe, front
to back” examination of the
patient. See the ‘major trauma
form’.
Adjuncts to 2 Survey
NG and IDC. Special investigations including CT or angiography as indicated
Definitive Care
A formal hand-over to the
accepting speciality.
o
E.Trauma Team Membership
and Roles
Membership
•
The team membership is as follows:
•
Trauma team leader
•
Critical Care Medicine Registrar
•
Emergency Medicine Registrar
•
General Surgery Registrar
•
Airway nurse
•
Circulation nurse
•
Senior nurse
The trauma team leader is a consultant. This responsibility
may be delegated to another individual. Overnight this
delegation is automatically given to the senior ED doctor.
The trauma team leader is clearly identified by placing the
“trauma team leader” sticker on the scrubs. All trauma team
members must have their roles delineated before the arrival
of the patient.
The team leader does not change during a trauma call.
All doctors make themselves known to the team leader
before becoming clinically involved with the patient.
Roles
Know your role prior to being a team member. The Trauma
Team leader will delegate specific tasks when required.
Team Leader
•
Decisions
•
Direction
•
Destination
•
Documentation
Responsibilities:
1.
Ensure team is complete and roles allocated prior to
patient arrival
2.
Obtain essential history from pre-hospital care providers
3.
Ensure team members perform their roles in a timely fashion
4.
Prioritise injuries and the investigation and management
thereof
5.
Facilitate passage of patient to definitive care and radiology
6.
Reach agreement with the trauma team members on
treatment plan and timeframe
7.
Contact other specialities (e.g. Orthopaedics or
Neurosurgery)
8.
Initiate Massive Transfusion Protocol as required
http://adhbintranet/anaesthesia/guidelines/mtp13.pdf
9.
Speak with relatives
10. Ensure appropriate documentation is completed by team
members
When possible this should be a ‘hands off’ role.
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Auckland City Hospital Trauma Team Guidelines | June 2016
Critical Care Medicine Registrar
•
Primary Survey: A, B and D.
Responsibilities:
Prior to patient arrival
•
Check and prepare airway equipment
1.
Communicate with the patient
-- oxygen & suction
2.
Establish patent airway and give oxygen
-- intubation equipment
3.
Ensure in-line stabilisation of the cervical spine
4.
Establish and maintain ventilation
5.
Evaluate neurological status
6.
Monitor ECG and vital signs
On patient arrival
7.
Insert arterial line as required
•
Ensure C-spine stabilisation
8.
Place a gastric tube (orally if the nasal route is contraindicated)
•
Assist with patient transfer onto bed
•
Assist with initial airway management
•
Cut clothes on patient’s right when airway secure
Emergency Medicine Registrar
•
Primary survey: C and E
•
Arrange trauma radiology
•
Secondary survey
-- ventilator/capnograph
-- Draws up intubation drugs
During intubation
•
Assist with intubation
•
Ensure cricoid pressure is applied (by another member
of the team) if request from airway doctor
Responsibilities:
•
Secure ET tube and attach to ventilator & capnograph
1.
Stop external bleeding with pressure
•
Assist with insertion of NG tube
2.
Complete primary survey (C & E)
•
Apply lacrilube
3.
Insert large bore cannulae (14g/16g in antecubital
fossae)
Ongoing care
4.
Take trauma bloods (including ethanol) and cross
match suspended red cells
5.
6.
•
Ongoing monitoring of airway & ventilation
•
Record ECG
Start fluid resuscitation with crystalloid
•
Assist with/performs IDC - dipsticks & sends spec
Complete secondary survey including FAST scan where
relevant
•
Assist with chest drain insertion / DPL /USS / other
procedures
General Surgery Registrar
Prior to transfer
•
Total drainage output – IDC / chest drain & informs
documentation nurse
Confirm the secondary survey findings.
•
Ensure portable oxygen available
Perform invasive examinations.
•
Prepare transport box & drugs
•
Expedite surgical and radiological intervention.
•
•
Responsibilities:
4
Procedural Nurse
1.
Intercostal drainage
2.
Arrest external bleeding
3.
Urinary catheterisation
4.
FAST scan and/or Diagnostic peritoneal lavage (DPL)
where indicated
5.
Review secondary survey
6.
During logroll, examine back and perform rectal
examination
7.
Arrange CT, angiography if indicated
8.
Arrange OR appropriate and gain consent
Circulation Nurse
Prior to patient arrival
•
Ensure IV trolley available
•
Prime IV lines
On patient arrival
Nurse Co-ordinator – Senior Nurse at Foot of
Bed
Prior to patient arrival
•
Designate nursing roles & liaise with team leader
•
Identify team members
•
Prepare documentation – ensures R40 attached to front
of resus record
•
Switch timer on
•
Assist with patient transfer onto bed
•
Inform blood bank and x-ray as appropriate
•
Cut clothes on patients left
•
Ensure rapid infusion device is set up as indicated
•
Attach Propaq
•
Ensure art line is set up as indicated
•
Perform initial obs (place saturation probe on as 1st
action) - BP, P, RR, temp, GCS, 02 sats. Inform team
of readings
On patient arrival
•
•
Assist with control of haemorrhage
Document:
-- time of arrival
During intubation /iv access
-- history from ambulance officers
•
Assist with IV lines & fluid infusion
-- patient status
•
Administer IV drugs
-- baseline recordings including GCS and pupil reaction
Ongoing care
•
Prepare paperwork
•
Liaise with clerks re: patient details / valuables / sending
bloods
•
Attach ID band
•
Label and secure property
•
Continued obs - BP, P, RR, temp, GCS, 02, CO2, MAP & informs team
•
Set up arterial line monitoring
•
Continue with administration of IV fluids / drugs
•
Apply splints / dressings
During intubation/iv access
•
Notify documentation nurse of fluids/drugs administered
•
Document time / drug / dose etc
Prior to transfer
Ongoing care
•
Ensure necessary equipment & fluids available
•
Co-ordinate nurses to assist with log roll
•
If patient is going to a ward ensure arterial line is removed
•
Continue with documentation
•
Provide team with regular updates
•
Access drugs
•
Double check all infusions where necessary (e.g. blood)
•
Ensure specimens are labelled & sent
•
Liaise with social worker or ED charge nurse for the
ongoing care of the family
Prior to patient transfer
•
Liaise with MBOR / DCCM charge nurse/ duty manager
•
Keep ED charge nurse informed
•
Ensure documentation completed
•
If transferring patient to a ward ensure:
-- Fluid total input / output is transcribed onto hospital
fluid balance chart
-- Ongoing medication is transcribed
•
Makes decision regarding most appropriate transfer
nurse
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Auckland City Hospital Trauma Team Guidelines | June 2016
Paramedics
Document on white board:
•
Patient identity – name, age, gender
-- Mechanism of injury
•
G.Primary Survey (ABCDE)
ABCDE
The primary survey is achieved through parallel tasking.
Knowing your role makes this possible.
Airway (with C-spine control)
-- Location of injury
1.
Assess the airway and determine its adequacy
Injuries
2.
Create or maintain an airway by
-- Signs and Symptoms
a.Looking with suction
•
Relevant Medical history
b.Chin lift or jaw thrust
•
Allergies
c.Naso/Oropharyngeal airway
•
Medications prescribed
•
Other Information
•
Print e-PRF for inclusion in patient notes.
F. Standard precautions
d.Orotracheal intubation
e.Cricothyroidotomy
3.
Recognise the potential for cervical spine injury and
maintain the spine in a safe neutral position until clinical
examination and radiological findings exclude injury.
4.
Indications for intubation
Standard infection control and safety precautions should be
maintained for all patients including trauma calls.
This includes:
•
Wash hands before and after all patient or specimen
contact
•
Wear gown and gloves for potential contact with blood
and body fluids
•
Wear protective eyewear and mask
Plastic aprons, protective visors and gloves are always
available.
Refer to Auckland DHB Infection Control Manual
-- Airway or breathing compromise (present or
predicted)
-- Unprotected airway
-- GCS < 9
-- Combative and uncooperative patients to facilitate
on-going investigation and management in a safe
environment for patient and staff
Breathing
1.
Administer high flow oxygen
2.
Assess the chest by
The risks just aren’t worth it!
a.Inspection
b.Palpation and feeling for the trachea
c.Percussion
d.Auscultation
3.
Recognise and treat:
a.tension pneumothorax
b.massive haemothorax
c.flail chest
d.sucking chest wounds
e.pericardial tamponade
6
Circulation
Assess circulation by
a.Looking for external haemorrhage
b.Observing skin colour, temperature and capillary refill
c.Feeling the pulse
d.Taking the blood pressure
e.Checking neck veins
The patient with cold pale peripheries has shock until
proved otherwise
Exposure/Environmental control
1.
Expose the patient so that an adequate complete
examination can be performed.
2.
Prevent the patient becoming hypothermic, measure
their temperature
Resuscitation and monitoring
Ongoing resuscitation of physiological abnormalities
detected in the Primary Survey is very important. Monitoring
of the progress of this resuscitation requires consideration of
the following:
1.
Respiratory rate
2.
Perfusion
Insert at least two large bore (>16g) IV cannulae
3.
Pulse (palpation, ECG monitor +/- wave form)
a.Tibial or Humeral Intraosseus, Jugular or Femoral vein
Vascath, or venous cut down if lines not possible
4.
Blood pressure
5.
Oxygenation (pulse oximetry, ABG’s)
3.
Take the trauma bloods (FBC, relevant biochemistry,
venous gas, ethanol, cross match, and pregnancy test in
females of childbearing age).
6.
Urine output (urethral catheter should be inserted if not
contraindicated)
4.
Begin infusion with 1-2 litres of normal saline in adults.
7.
GCS
5.
Monitor the patient with an ECG monitor and a pulse
oximeter
1.
Arrest external haemorrhage by local pressure or
tourniquet
2.
All fluids should be warmed (up to 39°C).
In massive haemorrhage use the Belmont Rapid Infuser.
Exsanguinating patients get group O blood ASAP
Analgesia
Most trauma patients are in significant pain. Early pain
management is essential in conjunction with on-going resus
citation.
•
In general pain relief is aided by:
Patients with on-going haemodynamic instability despite
crystalloid resuscitation and suspicion of on-going
haemorrhage should receive early blood products –
initially O negative blood ± MTP activation as required.
•
Establishing rapport with the patient
•
Splinting of injured extremities
•
Gentle movement and handling
http://adhbintranet/anaesthesia/guidelines/mtp13.pdf
•
Prevention of shivering
•
Cooling of burns
Disability
1.
GCS
a.Are the eyes open ( ‘no’ means E3 or less)
Opioids should be given intravenously in severe trauma:
•
Titrate in small increments until the desired effect is
achieved.
•
Beware hypotension, respiratory depression and vomiting.
•
May require bolus dose to effectively work in a timely
fashion
b.Talk to the patient
c.Use painful stimulus to finger or toe if required (sternal
rub has difficulty distinguishing M3, 4 and 5 )
2.
Assess the pupillary size and response
3.
Examine for lateralising signs (e.g. differing motor
scores on each side) and signs of cord injury
4.
Blood Sugar Level
-- Morphine 0.1 mg/Kg
-- Fentanyl 1.0 mcg/Kg
Local anaesthetics – Regional Blocks/Local Infiltration
Femoral nerve block is very effective for the pain associated
with femoral fracture and is necessary in wounds to allow
effective exploration.
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Auckland City Hospital Trauma Team Guidelines | June 2016
Bloods
H. Secondary survey
1.
One set of trauma bloods should be sent to the lab for
FBC, U&Es, Creat, LFT’s, Coags
This assessment is a complete examination of the patient
from top to toe, both front and back.
2.
One tube for Group & Hold plus cross-match
Use the “Major Trauma Form”
3.
Venous blood gas
Radiology
The resuscitation room x-rays are as follows:
History
AMPLE history.
AAllergies
M
Medications (Anticoagulants, insulin and cardiovascular medications especially)
This is the only x-ray justified in an unresuscitated patient.
P
Previous medical/surgical history
The obvious clinical tension pneumothorax should be treated
before a CXR.
L
Last meal (Time)
E
Events/Environment surrounding the injury;
ie. Exactly what happened
Chest X-ray
Pelvic X-ray
A pelvic fracture that is not clinically obvious can be the site
of unexplained blood loss.
A dislocated hip can be missed in a patient with multiple
injuries, especially if unconscious.
Lateral cervical spine X-ray
Secondary Survey
Pitfalls:
1.
a.Posterior scalp lacs/compound skull fractures
This is not performed routinely and is at the discretion of
trauma team leader.
Allows early diagnosis clinically of C-spine injury, but does
not clear the C-spine.
b.Pupil changes since primary survey
c.Visual deficits
2.
Neck
a.Injuries under the hard collar are not seen
The C-spine cannot be cleared in the following circumstances:
b.In line immobilisation while the collar is off
a.history of loss of consciousness
c.Missed cervical vascular injuries – refer to CT Angiogram algorithm
b.abnormal level of consciousness
c.intoxication
Head and face
3.
Chest
d.unable to communicate
a.Clinical rib #s and sternal #s are missed
e.head or neck injury
-- many do not show on the chest X-ray
f. neck symptoms or C-spine tenderness
-- they can compromise the patient
g.a distracting injury
-- X-ray ‘proof’ is not required
When not cleared clinically, radiological examination is
required. This is usually a CT scan.
4.
Abdomen
a.Pain or tenderness or bruising requires further
investigation
b.The inaccessible abdomen with appropriate mechanism requires investigation.
-- FAST (or Diagnostic Peritoneal Aspirate) in the
unstable
-- CT in stable patients
c.Vaginal examination in female patients with pelvic
fractures or vaginal bleeding. In pregnancy this examination should be deferred to an obstetric
specialist.
8
d.A nasogastric tube is contraindicated in the presence of facial fractures (an orogastric tube should be
inserted)
e.A urinary catheter should only be inserted if there is
no blood at the urethral meatus, no perineal bruising,
and rectal examination is normal.
5.
Drainage of pneumothorax/haemothorax as indicated
7.
In-dwelling Catheter if indicated
8.
Pelvic Binder
9.
Tetanus
10. Prophylatic Antibiotics where indicated
Back
a.Log roll takes 5 people, 3 body, one head, one examining
6.
6.
Ethanol Levels
b.Inspection and palpation
Hospital ethanol
c.Perform the rectal examination at this time if indicated.
All trauma patients should have a hospital ethanol level taken
(trauma call or not).
Extremities
a.Inspect and palpate each limb for tenderness,
crepitation, or abnormal movement.
b.If the patient is cooperative ask him or her to move
the limbs in response to command in preference to
passive movement in the first instance.
Police ethanol
Police ethanol samples should be taken on all road crash
drivers when:
a.Requested by police, or
b.Patient smells of alcohol, or
c.Adequately splint any injuries.
c.An urgent hospital ethanol level is >3 mmol/l
d.Reassess after splints, traction or manipulation
7.
Neurological examination
a.Repeat the Glasgow Coma Scale – record scores for
E, V and M as well as the total score
b.Re-evaluate the pupils
c.Look for any localising/lateralising signs
d.Look for signs of cord injury
Initial Treatment
1.
Supplemental O2, ensure sats ≥ 94%
2.
Analgesia
a.IV – Morphine, Fentanyl
3.
IVF
a.Crystalloid
b.Blood Products
c.FFP, platelets (and cryprecipitate or fibrinogen
concentrate in some patients)
4.
Early Haemorrhage Control
a.Pressure – Direct, Tourniquet
b.Interventional
c.Surgical
5.
Manage Life-threatening chest injuries
The kit is available in the ED and samples can be taken
without police presence or request.
Elderly patients
Elderly patient present special challenges as they have
reduced physiologic reserve and their co-morbidities may
affect treatment options and outcomes. Pulmonary complications are common and thoracic epidurals or early ventilation
should be considered.
Early referral to gerontologist should be made for all elderly
patients in the post-resuscitative phase.
Pregnant Patients
Pregnant trauma patients require special consideration
because of the anatomic and physiologic changes that occur
in pregnancy and the fact that two patients are being treated
(mother and fetus). In general, the best treatment for the fetus
is the provision of optimal resuscitation of the mother.
•
In late pregnancy, displace the uterus to the left (e.g. by
elevating the right hip with a towel or pillow) to avoid IVC
compression and hypotension
•
Consider the need for anti-D therapy for Rh-negative
patients
•
Detect fetal heart sounds using auscultation or doppler
•
A obstetrician should be consulted early and asked to
attend the patients and provide CTG monitoring when
appropriate
a.Tension Pneumothorax
b.Pericardial Tamponade
9
Auckland City Hospital Trauma Team Guidelines | June 2016
Documentation
All members of the trauma team have a responsibility to ensure
their actions, findings, names and roles are recorded in a
legible fashion in the patient’s medical record. The Auckland
City Hospital Major Trauma Form is designed to document the
trauma call. It forms a part of the clinical record. When used,
other documentation is typically not required.
Definitive care decisions may require further documentation:
speciality, specialist, plans and prioritisation. When several
teams are involved explicit instructions (e.g. NBM, mobility,
observations etc.) are required.
10
Part 2: Injury treatment
A. Head Trauma
B. Prevention of Secondary Brain Injury
Algorithm for management of head injury patient is found in
Part 3.
Head injury is common and is frequently one of several
injuries. Head injury is a part of ‘D’, and as such A, B and
C injuries take priority. Once initial stabilisation has been
undertaken patients with GCS < 14 will require neurosurgical
assessment including CT scanning at some stage (Figure 1).
Basic neurological examination should include assessment of
the Glasgow Coma Scale noting not only the best response
but also any lateralising signs (i.e. also the worst response).
It should be remembered that hypoxaemia, shock, alcohol
and other drugs all depress the level of consciousness and
worsen the neurological signs. Analgesic and anaesthetic
drugs and muscle relaxants also interfere with neurological
assessment.
Glasgow Coma Scale
Response
Eye opening
Best verbal response
Best motor response
•
Adequate Oxygenation
•
Prevent Hypercarbia & Hypocarbia (Hypoventilation
and Hyperventilation)
•
Adequate Perfusion Pressure
•
Prevention of Hypoglycaemia
•
Reduce agitation
•
Early decompression when indicated
•
Use of:
--
Mannitol
--
4 Molar salt
--
Hyperventilation
C. Spinal Cord Trauma
Score
Algorithm for management of cervical spine injury is found in
Part 3.
Spontaneous
4
To voice *
3
Physical signs of spinal cord trauma include:
To pain
2
Nil
1
•
No movement of arms and/or legs
•
Abnormal peripheral vasodilatation
Oriented
5
Confused **
4
•
Lax anal sphincter tone
Inappropriate
3
•
Incomprehensible
2
Contusions/tenderness/deformity/crepitus on clinical
examination of the spine during the log-roll
None
1
•
Subjective and objective sensory changes
Obeying
6
Localising
5
Withdrawal
4
Abnormal flexion
3
Extension
2
None
1
* A patient who does not open their eyes to normal requests
to do so is E3.
**A patient who does not know the day of the week is V 4.
In general patients should go to the OR for haemostatic
surgery prior to having CT scans of the head, although each
case needs to be considered on its merits.
The only cervical spine view indicated in the emergency
room is the lateral view. The cervical spine must remain
protected until the patient is stable enough to undergo the
3 film cervical series, performed either in the radiology suite
or in DCCM. “Clearance” of the cervical spine is undertaken
according to the guidelines in figure 2 (Appendix).
Any patient who has a cervical spine injury or severe blunt
trauma requiring admission to DCCM should have screening
AP and Lateral x-rays of the entire thoracic and lumbar spine.
Patients with clinical signs of thoracic or lumbar spine injury
similarly require radiologic evaluation.
Presently at ACH steroids are not used in the acute management of cord injuries.
Any patient with isolated spinal cord impairment, refer to the
Supra-Regional Spinal Cord Injury Guidelines. These patients
are transferred as soon as possible to Middlemore Hospital.
11
Auckland City Hospital Trauma Team Guidelines | June 2016
D. Chest Trauma
Algorithms for management of blunt and penetrating chest
trauma are found in Part 3.
Injuries that immediately compromise ventilation and oxygenation should be identified during the initial assessment of the
trauma patient and treated appropriately. Examples include
pneumothorax and haemothorax. These patients are always
admitted.
Some injuries result in severe respiratory compromise hours
or even days after injury. Minor injuries can be a marker
for more severe injuries. The Trauma Service has a liberal
admission policy for patients with seemingly minimal chest
trauma.
Patients with the following conditions will be admitted:
All trauma patients with an “appropriate mechanism of injury”
(total body acceleration/deceleration e.g. road crashes [incl.
pedestrians and cyclists] and falls >1 storey) are at risk for
thoracic great vessel injury. Concerns must be discussed
with consultants.
Suspicious clinical signs include:
•
neck haematoma
•
unilateral diminution or loss of pulse, asymmetric BP
•
radiofemoral delay (pseudocoarctation)
•
severe searing transthoracic pain
AP chest x-ray signs include:
•
Widened mediastinum >8cm
•
Loss of normal aortic contour
•
Opacification of aorta-pulmonary window
•
Apical capping
•
Displacement of main stem bronchi (left down, right up),
NG tube to the right
Subcutaneous emphysema
•
Fracture of first rib, scapula
6.
Traumatic asphyxia
7.
Flail segment
The widened mediastinum requires further investigation, most
commonly with CT aortogram.
8.
Chest trauma associated with an arrhythmia or other
evidence of myocardial injury.
1.
Sternal fractures
2.
Any 1st, 2nd or 3rd rib fractures
3.
More than 1 rib fracture in any region (We might not
admit an otherwise fit and healthy patient on the basis of
a single rib fracture)
4.
Pulmonary contusion
5.
Co-morbid (e.g. CORD, warfarin etc.) and elderly patients
may be admitted following any chest trauma.
Patients with chest injuries are admitted under general
surgery unless they require admission for another injury
requiring surgery i.e. orthopaedic/neurosurgical. They can be
referred to the Trauma Service for continuing care as a ward
referral. Chest injury patients should not be admitted under
medical service due to pain service availability and differing
nursing skills. All should receive supplemental oxygen as
needed, chest physiotherapy, and adequate analgesia.
Consultation with the Pain Service on the day following injury
should be considered.
Indications for tube thoracostomy
Tube thoracostomy (chest tube insertion) is indicated in the
following circumstances.
12
E. Aortic Injury
1.
Haemothorax on chest x-ray
2.
Significant pneumothorax (>20% loss of diameter on
chest x-ray)
3.
Severe lung injury or any pneumothorax, no matter how
small on chest x-ray, in a patient who is to be transported by ground or air, or is to undergo GA or positive
pressure ventilation
4.
As a diagnostic / therapeutic procedure in the unstable
multi-trauma patient with suspected internal haemorrhage into the chest
5.
Small pneumothorax or surgical emphysema if patient is
to undergo positive pressure ventilation.
A widened mediastinum does not necessarily mean an
abnormal mediastinum and an abnormal mediastinum
may not necessarily be widened.
The investigations for great vessel injury are:
CTA Chest
•
Can be helpful in resolving the diagnosis of abnormal
mediastinum
•
Requires the appropriate CT protocol (thoracic aorta
dissection protocol)
•
Can identify injuries that may otherwise be missed on
plain films
•
Is not useful for mediastinal haematoma if anatomical
boundaries are obliterated by undrained haemothorax
etc.
In general, the investigation and the treatment of aortic
rupture should follow treatment of expanding intracranial
haemorrhage or active chest, abdominal, or pelvic bleeding.
F. Penetrating Chest Trauma
Algorithms for management penetrating chest trauma are
found in Part 3.
Penetrating wounds to the chest are relatively uncommon
presentations to Auckland City Hospital. Many will cause
pneumothorax or haemothorax and require chest drain. Occasionally mediastinal or cardiac injuries occur. Penetrating
cardiac injuries have a high mortality and only 25% (2 or 3
each year) survive to reach our hospital. Diagnosis before
tamponade is associated with better outcomes than waiting
for cardiac arrest.
Any patient who is haemodynamically unstable after a stab
wound to the chest needs the cause established as soon
as possible. Finger thoracostomy and tube or chest drains
will identify tension pneumothorax or massive haemothorax.
Undertake a FAST scan to assess bleeding into the abdomen
or pericardium.
In stable patients, clinical examination combined with chest
x-ray can be used to evaluate the lungs and pleural cavities
but these modalities are insensitive for cardiac injury.
When patients have been stabbed in “the box” the possibility
of cardiac injury exists. (“The box” is that part of the anterior
chest and abdomen bounded by the clavicles superiorly,
the mid-clavicular lines laterally, and the costal margin in the
mid-clavicular line.)
Lung laceration
•
Aortic clamp across the area of bleeding (hilum if
necessary). Tell the airway doctor (so ventilation can be
adjusted).
Hypovolaemic asystole
•
Clamp the descending aorta just above diaphragm.
Incise the pleura anterior and posterior to the aorta,
separate from the oesophagus. Clamp just the aorta.
Check the clamp will not fall off.
Internal cardiac massage
•
Use the flat of your hands, one in front one behind, as
using your fingertips can penetrate the heart. Use the
internal paddles if defibrillation is required.
When to stop:
•
The injuries are found to be irreparable (e.g. blunt
cardiac rupture), volume replacement is not achieved
within 15 minutes of thoracotomy (i.e. the heart remains
empty) or the heart is not in a self-sustaining rhythm after
30 minutes
Indications for operating room thoracotomy
1.
At Auckland City Hospital, <5% of blunt trauma patients
and approximately 25% of penetrating trauma patients
undergo operating room thoracotomy. The indications
are as follows:
Cardiac injury can be identified by: FAST scan, echocardiography, pericardial window or thoracotomy. All of these are
operator and skill dependent. Get consultant input immediately for suspected cardiac injury.
2.
Massive haemothorax (>1500ml blood drained
immediately from chest tube)
3.
Ongoing bleeding (>200ml/hr for 2-4 hours, ongoing
transfusion requirement)
Thoracotomy procedure
4.
Significant undrained haemothorax following chest
drain insertion warrants thoracotomy or thoracoscopy to
evaluate.
This procedure is a desperate measure performed to try and
save “agonal” patients. Most patients will die (70 to 90%). In
blunt trauma 99% will die.
5.
Cardiac tamponade, confirmed by FAST scan or
subxiphoid window
6.
Mediastinal traversing wounds, i.e. cross the midline
Indications: A penetrating injury to the chest, where the
patient is dying in front of you and will not survive the trip to
theatre, and vital signs were present either on arrival in the
ED or within the previous 15 minutes but are now absent.
Vital signs include a palpable pulse, electrical cardiac
activity on an ECG monitor, spontaneous respiration, or
reactive pupils.
7.
Specific injury requiring surgical intervention (e.g.
tracheobronchial, oesophageal)
Emergency Department Thoracotomy
Procedure:
Tell the consultant surgeon on call this is happening.
The airway doctor advances the ET tube into the right main
bronchus. The operating doctor makes a long left thoracotomy incision (5th space). Extend across the sternum if
required. Use the Finochietto retractor. Have good access
before proceeding.
Then (dependent upon findings):
Pericardial tamponade
•
Identify the phrenic nerve. Open the pericardium
anterior to the phrenic nerve. Evacuate the clot. Plug
the hole in the heart (finger, IDC, suture, skin stapler).
13
Auckland City Hospital Trauma Team Guidelines | June 2016
G. Abdominal Trauma
•
Algorithm for evaluation of the abdomen is found in Part 3.
Refer to Appendix I: Evaluation of abdomen in the blunt
trauma patient
Injuries may be identified in the primary survey (breathing:
diaphragmatic hernia, circulation: blood loss). Decisions for
laparotomy may be based on history and exam findings or
via the primary survey adjuncts (FAST scan).
The FAST scan should take between 1-5 minutes and has the
advantage that it is repeatable and non-invasive. The FAST
operator should document the findings in the notes. When
a credentialed operator is present, this investigation has
acceptable sensitivity to exclude haemoperitoneum, cardiac
tamponade and pleural fluid or blood.
The history of abdominal pain, may be all that points to
significant intra abdominal injury. Signs may include the ‘seat
belt’ sign, abrasion or bruising, and/or abdominal tenderness
and/or gross haematuria. Abdominal CT may identify occult
injuries in stable patients.
Patients with altered GCS or who are or will be intubated
cannot be reliably assessed for these findings, or monitored
for evolving peritonitis. Abdominal CT scan can be used to
‘screen’ these patients for occult injury.
Abdominal CT reports should include: organ injuries (or absence of), free fluid, air or contrast and fractures identified.
Blunt Splenic Trauma
Imaging will be performed as detailed below* on blunt
trauma patients who do not have immediate indications for
theatre i.e. peritonitis, hypotension.
Evidence of splenic trauma with contrast extravasation, false
aneurysm, and/or arteriovenous fistula will proceed directly
to angiography from emergency department. This will be organised by phone call from the most senior surgical registrar/
consultant available to the interventional consultant.
Any grade 3+ splenic injury without the above findings will
prompt a phone call from the surgical consultant to the
interventional consultant. If the surgical consultant is not
available within 20 minutes to make this call, the most senior
surgical fellow/registrar will initiate the communication.
Factors that may prompt angiography in the absence of
contrast extravasation, false aneurysm, and/or arteriovenous
fistula include but are not limited to:
14
•
Significant hemoperitoneum
•
Clinical findings concerning for impending instability
--
Haemoglobin drop
--
Tachycardia
--
Hypotension
--
Fluid requirement >1L or blood product
requirement
Patients who are higher risk for complications from hypotension and/or laparotomy
--
TBI
--
Elderly/comorbid
If it is decided that the patient not require immediate angiography, a plan will be put in place to allow for prompt reconsideration should the patient’s condition change. Ideally the
patient will be admitted to a monitored setting i.e. HDU.
*Imaging (pertains only to those patients who do not require
a chest CT; these patients will continue as before)
•
•
Dual phase abdominal CT (arterial upper abdomen,
portal venous abdo and pelvis)
--
Resus patients coming through as a trauma call
--
Non resus patients with positive FAST Dual phase abdominal CT including pelvis (arterial
abdo and pelvis, portal venous abdo and pelvis):
--
•
Patients with unstable pelvic fractures.
Single phase abdominal CT (portal venous phase abdo
and pelvis)
H. Penetrating Abdominal Trauma
J. Genitourinary Injuries
Algorithm for management of penetrating lower chest or
abdomen stab wound is found in Part 3.
Anterior pelvic fractures are associated with a high rate of
bladder and urethral injuries.
Because the diaphragm reaches the level of the fourth intercostal space on full expiration, any penetrating wound below
the nipples anteriorly or tips of the scapulae posteriorly are
considered potentially abdominal. Gunshot wounds mandate
laparotomy.
Cystogram can be used to investigate these injuries. Gross
haematuria with anterior pelvic fractures will likely have
bladder rupture as a cause.
I. Pelvic Trauma
Algorithm for management of fractured pelvis is found in
Part 3.
The pelvis should be assessed clinically as part of the
Secondary Survey. Be gentle when examining the patient
1. Look •
Abrasion or bruising over bony prominences.
•
Scrotal or perineal haematoma.
•
Blood at the urethral meatus.
•
Leg length discrepancy
2. Feel/move
•
Posterior compression of iliac wings
•
Medial compression of iliac wings
•
Compression of pubic symphysis
•
Hip flexion and rotation
•
Rectal examination
All “impaired” patients and any patient with signs or
symptoms of pelvic injury should have a plain AP x-ray of the
pelvis. When fractures are identified, orthopaedic
consultation is necessary.
If a patient with a pelvic fracture is haemodynamically unstable a FAST scan is required:
•
If grossly positive, the patient must go to the OR for a
laparotomy.
•
If grossly negative then pelvic angiography and
embolisation of arterial bleeders is next step.
In major pelvic injury, stressing the pelvis should be
avoided as it may dislodge vital clot.
•
•
An alternative to cystography in the screening room is a CT
cystogram. (The bladder is filled with 300 ml of contrast prior
to obtaining a CT ‘run’ through the pelvis. Post-drainage
views of the bladder are then taken).
Retrograde urethrogram is required for the patient with:
blood at the urethral meatus, scrotal bruising, high-riding
prostate on PR or the stable patient with multiple grossly
displaced superior and inferior pubic rami fractures.
An IDC may still be passed with gentle advancement but
any resistance should stop procedure and alternate bladder
drainage sought.
K. Extremity Trauma
Look for deformity or bruising, feel for pain and listen for
bruits over haematomas.
Do a neurovascular exam.
X-ray suspicious areas, including the joint either side. A
common missed injury is the fracture distal to a fracture in the
same limb.
Wounds should be accurately described, so subsequent
examinations are not required. Repeated examination of
wounds that are under sterile dressings is counterproductive.
After splinting or traction the neurovascular state of the limb
is reassessed.
Femur fractures should be immobilised and femoral nerve
blocks done.
Dislocated joints (except native hip joints) and fractures
should primarily be managed with relocation within resus first
prior to OT or other definitive treatment.
Native hip joint dislocations should go to OR for proper
assessment. Always come if intubated and ventilated
already. Check with Ortho.
Orthopaedic stabilisation of mechanically unstable
pelvic fractures follows laparotomy or angiography to
reduce venous loss.
Make sure you have seen the entire patient.
Intensivist, orthopaedic and trauma specialists should
be involved early.
External injuries are rarely life-threatening, however active
bleeding should be stopped.
L. External Trauma
In penetrating injury the most obvious injury may well not be
the most important injury.
Multiple injuries are common.
In blunt injury, external signs often provide clues to other
more serious but less obvious injuries. Clinical rib fractures
and the seat-belt sign are good examples.
15
Auckland City Hospital Trauma Team Guidelines | June 2016
Part 3: Algorithms
Trauma Code Crimson
Trauma Call Criteria met on R40
Penetrating mechanism
(1)
Systolic BP <90mmHg
(1)
Pulse rate >120
(1)
+’vTrauma E-FAST Ultrasound
(1)
Score
Score 2,3 or 4
1.
Emergency Department (ED) Charge Nurse or
Specialist organise:
-- 777 Trauma Code Crimson with expected
time of arrival (ETA) and Adult ED
2.
ED Charge Nurse to ensure the following teams
are contacted with, Trauma Code Crimson and ETA:
-- Anesthetist 021 496 374
-- Level 8 Nursing coordinator 021 492 086
-- Blood bank 24015
-- Radiology Registrar 021 412 581
16
3.
Surgical Registrar to contact on call
Surgical Consultant
4.
If Emergency Department Specialist not in
hospital to be contacted by Charge Nurse
Score 0 or 1
If Trauma call Criteria met:
777 Trauma Call with ETA and Adult ED
Traumatic Cardiac Arrest
Life threatening trauma
•
Stop bleeding
•
Open airway
•
Decompress chest & assist breathing if necessary
•
Fluid resuscitation (aim SBP >90mmHg or consciousness)
•
Early damage control surgery
Traumatic cardiac arrest
YES
Obvious non-reversible cause
Do not attempt resuscitation
Open airway
Consider airway devices e.g. ETT, supraglottic airway
No Return of Spontaneous Circulation
•
IC or IO access
•
20ml/kg IV plasma/RBC or crystalloid
•
Further 5 – 10 ml/kg fluid bolus if indicated
•
Control likely sites of haemorrhage e.g. direct pressure, tourniquet
YES
No ROSC
•
Decompress chest – finger or needle thoracostomy followed by insertion of
YES
intercostal catheter
No ROSC
•
USS (if available) to assess pericardial tamponade
•
Resuscitative thoracotomy if tamponade identified (or, if USS unavailable,
•
Consider needle pericardiocentesis only if surgical intervention is not possible
No ROSC
•
YES
likely given the known mechanism)
Consider resuscitative thoracotomy to clamp descending aorta, control thoracic
haemorrhage and facilitate internal cardiac compressions and internal
defibrillation
•
Post resuscitative care
•
Prioritise surgical
•
Aim SBP > 90mmHg
haemorrhage control
until this is achieved
No ROSC
•
Conventional BLS, ALS or internal cardiac compressions for 10 mins after all
possible reversible causes addressed
No ROSC
YES
Cease resuscitation
17
Auckland City Hospital Trauma Team Guidelines | June 2016
Management of the head injured patient
ABCDE
Resuscitation
Neurological examination
GCS 14-15 Mild HI
No risk
factors
(see table 1)
Discharge with
head-injury
advice sheet
Risk
factors
(see table 1)
Probably CT
likely admission
GCS 9-14
CT head
Admission/observation
Improve
(90%)
Discharge when
appropriate with
follow-up
Deteriorate
(10%)
Treat as per
severe head
injury
GCS 3-8 Severe HI
Surgically
Not surgically
on CT
on CT
correctable lesion
Operate
correctable
Intensive
care
Risk Factors: Indicators of an increased risk of a significant intracranial lesion in a patient with apparently mild head injury
18
•
Penetrating head injury
•
Moderate to severe headache
•
Amnesia
•
Skull fracture
•
History of loss of consciousness
•
Deteriorating level of consciousness
•
CSF leak, rhinorrhoea or otorrhoea
•
Abnormal CT scan
•
Alcohol or drug intoxication
•
Significant associated injuries
•
No reliable companion at home
•
Unable to return promptly
•
Anticoagulation – Warfarin, Dabigatran, Clopidogrel, Other
Management of the cervical spine in trauma
History
ABCDE
Secondary survey
Spinal & neurological examination
High risk mechanism of injury
Not high risk mechanism of injury
Associate Injuries
Reliable normal examination
No X-ray required
Abnormal examination
Not Intubated
X-ray (3 views)
– lateral (to T1)
Normal radiological findings
Remove collar
CT neck from
– AP
base of skull to T1
Pain
Pain
– odontoid view
No pain
Intubated for head CT
Normal radiological findings
Abnormal radiological findings
Orthopaedic review
Continue C-spine protection
Consider MRI
19
Auckland City Hospital Trauma Team Guidelines | June 2016
Indications for CT Angiogram
Clinical indications
Radiological indications
•
Arterial haemorrhage from neck/nose/mouth
•
•
Cervical bruit for patients <50 years old
-- CHI consistent with DAI and GCS <6
•
Expanding cervical haematoma
•
Focal neurologic deficit inconsistent with CT findings
-- Skull base fracture (including occipital condyle
fracture)
(i.e. TIA, hemiparesis, vertebrobasilar symptoms,
Horner’s Syndrome)
•
Head Acute Infarction
Face
--
•
LeFort II or LeFort III
C-spine
--
Any C1-3 fracture
--
Any vertebral body fracture
--
Transverse foramen fracture
Clinical or radiological
indications present?
YES
Do CT-Angiogram
20
NO
No CTA required
Management of chest trauma
Primary survey (ABCDE)
Address life threatening issues
as per standard EMST
Secondary survey
Prompt log roll to identify all wounds Prompt CXR and AXR
Mark wounds with paper clips for X-ray identification
(Open clips for posterior wounds, closed for anterior wounds)
Abnormal CXR
Non-haemo/pneumothorax findings
e.g. widened mediastinum,
elevated hemidiaphragm
No injury noted on CXR
Haemo/pneumothorax
Symptomatic or moderate/large size
26 french chest drain if fluid is present
on CXR
For isolated pneumothorax may place a
smaller 12/14 french drain
CTA chest to evaluate for vascular or
diaphragm injury If any further clinical
concerns
CTA chest to evaluate for vascular
or diaphragm injury
if any clinical concerns
Asymptomatic or small
Repeat CXR in 6 hours to
elevate progression
Consider discharge home unless other injuries
require admission
21
Auckland City Hospital Trauma Team Guidelines | June 2016
Management of patient with chest wall trauma
Patients with significant anterior chest wall trauma
Haemodynically stable
ECG and troponin
ECG new abnormality
and/or elevated troponin
Haemodynically unstable
Urgent ECHO
Alert Critical Care and Cardiothoracic
Any new
haemodyamic instability
Flexi-monitoring for 24 hours
Repeat troponin in 8 hours
Cardiology inpatient referral ECHO within 24 hours
Normal values
No further arrhythmias
Decreasing troponins
Normal ECHO and/or cleared by cardiology
Discharge home if no other
injuries requiring admission
22
Abdominal evaluation in the blunt trauma patient
ABCDE
Abdominal examination
Haemodynamically stable
Normal examination
unreliable
abdominal signs
repeated abdominal
(Patient not available
examination)
Perttonitis/haemodynamically unstable
Equivocal or unreliable
Positive abdominal signs
abdominal signs present
Equivocal or
Cooperative patient
(Available for
Haemodynamlcally unstable
FAST scan + DPL
Positive
Laparotomy
present
for abdominal
examination)
Negative
Search for other
Observe
CT
sources of
haemodynamic
instability
23
Auckland City Hospital Trauma Team Guidelines | June 2016
Management of penetrating lower chest or abdominal stab wound
Primary survey (ABCDE)
Address life threatening issues as per
standard EMST
Secondary survey
Prompt log roll to identify all wounds
Prompt CXR and AXR
Penetrating chest injury
Mark wounds with paper clips
– see separate guidelines
for X-ray identification
(Open clips for posterior wounds,
closed for anterior wounds)
Gunshot wound or
other projectiles
Stab wound
Ensure even number of bullets and wounds
(i.e. If I bullet in abdomen and 2 wounds, look
Determine region of injury
for additional wound)
Abdomen
Flank
Whether clinical ex-
Abdomen/flank
CT abdo/pelvis with
amination reliable
contrast (rectal, IV)
Yes
Exploratory laparotomy
(may consider laparoscopy for
Serial abdominal examination
May be discharged after 24
stable patient and
hours if normal exams
Note: Completely benign
Alternatively, if patient could be
discharged otherwise, can perform local wound exploration and
discharge immediately if no facial
penetration
experienced laparoscopist)
abdominal examination
May consider CT to determine
No
Unreliable
examination
(perform local
wound exploration)
Extravasatlon of
contrast
trajectory with low threshold
for operative exploration given
possible blast effects
No contrast
extravasation
abdominal
Facia breach
Exploratory
laparotomy
*abdomen = any wound from nipples to groin anteriorly and scapulae to gluteal crease posteriorly
*unreliable due to brain Injury, intoxication, spinal cord injury, intubated/sedated etc.
24
Observe
then d/c
Management of fractured pelvis in the trauma patient
Primary survey (ABCDE) Address
life threatening issues as per EMST
Labile haemodynamics
Haemodynamically stable
Activate massive transfusion protocol
Consider transexamic acid
Apply pelvic binder
Secondary survey
Apply pelvic binder if significant diastasis
CXR/AXR/pelvic X-ray
CXR/AXR/pelvic X-ray and FAST scan
(do NOT delay FAST scan for secondary
survey)
Orthopaedics notified once significant
fracture confirmed
Consultant notification
(surgical, orthopaedics, intervenional)
FAST positive
FAST negative
CT abdo/pelvis with arterial and
portal venous (additional CT scans
Laparotomy for pelvic
fixation and/or pelvic
packing in OT
If patient
still remains
haemodynamically
labile IR consultant
to be notified
as per injury mechanism)
Perform diagnostic
DPT +ve
(gross blood)
peritoneal tap
(request angio suite
to be prepared)
Extravasation noted,
notify IR consultant
DPT -ve
No extravasation
noted
Proceed to angiography
- If patient from ED, DCCM registrar
accompanies
Abdominal bleeding
identified
Patient
haemodynamically
stable
- if patient from theatre, anaesthesia
accompanies
Extravasation noted
Notify IR consultant
Develops
haemodynamlc
instability
CT scan to evaluate pelvic
bleeding + any other
appropriate scans
based on injury mechanism
Manage other injuries as
appropriate
25
Auckland City Hospital Trauma Team Guidelines | June 2016
Part 4: Northern region inter-hospital
transfer guidelines
Northern Regional Trauma Network
1. These criteria should prompt bypass or immediate transfer to definitive care facilities. Startship (paeds) and
Auckland (adults) is the definitive care facility for most multi–trauma.
2. This is a guideline only. It does not replace clinical judgement.
3. All transfers must be safe and confer clinical benefit to the patient.
4. Notification between senior transferring and accepting medical staff precedes all transfers.
5. These guidelines have been agreed by all involved clinicians and endorsed by the four Northern Region CMOs.
Trauma inter-hospital transfer guidelines for Auckland and Starship Hospital
Condition
Go To
Regional
referral centre
P = Paeds
A = Adults
Comment
Traumatic Brain Injury
All brain injuries
Starship/Auckland
P/A
Spine
Suspect spinal injury, no motor deficit
Starship/Auckland
P
Spinal cord injury:
• Isolated with motor deficit
• Multitrauma but not TBI or chest injuries
Paeds – Starship
Adults – Middlemore
P
Spinal cord injury – with other major injuries such as TBI or
chest
Starship/Auckland or
Middlemore
P/A
Starship/Auckland
P/A
Refer to Supra-regional Spinal Cord Injury
Guidelines
Adults – determine whether appropriate to
transfer to Middlemore Hospital
Vascular Injuries
Blunt Carotid/Vertebral Injuries
Burns/Plastics
Burns > 20% or less but affects special sites
Middlemore
Refer to Burn Guideline
D/w Burn Service at Middlemore on 09 250 3800,
and fax referral to 09 276 0114
Burns <20%
Degloving of face or other special sites or extensive / complex
facial lacerations
Refer to Burn Guideline
D/w Burn Service at Middlemore if grafting
required
Middlemore
D/w Plastic Surgical Registrar at Middlemore
on 021 784 057
Maxillo Facial
All Max Fax injury – Paeds
Starship
Isolated Max Fax injury – Adults
Auckland
Max Fax injury with TBI or chest injuries – Adults
Auckland
P
D/w Max Fax at Middlemore
D/w Max Fax (021 292 1593) or Plastic Surgical
Registrar (021 784 057) at Middlemore
A
D/w Max Fax at Middlemore
Chest
All chest injuries
Starship/Auckland
P/A
Starship/Auckland
P/A
Abdominal Injuries
All abdominal injuries
Special limb injuries
Upper limb with major nerve injury, +/- arterial injury
Middlemore
Upper limb with arterial injury (but no nerve injury)
Starship/Auckland
Upper limb - amputation of viable digit (excluding simple
terminalisation) or partial limb amputation
Middlemore
Call Plastic Surgical Registrar at Middlemore on
021 784 057
Mangled lower limb with tissue loss
Middlemore
Refer to Mangled Limb Algorithm.
D/w Orthopaedic Registrar at Middlemore on
021 594 764
Lower limb - penetrating injury with major nerve injury +/arterial injury
Middlemore
Call Plastic Surgical Registrar at Middlemore on
021 784 057
Lower limb
• penetrating injury with arterial injury (but no nerve injury)
• blunt injury with ischaemia +/- nerve injury
Call Plastic Surgical Registrar at Middlemore on
021 784 057
P/A
P/A
Orthopaedic
All orthopaedic injuries
Starship/Auckland
P/A
Starship/Auckland
P/A
Urology
All urology injuries
26
Northern Regional Trauma Network
1. These criteria should prompt bypass or immediate transfer to definitive care facilities. Startship (paeds) and
Auckland (adults) is the definitive care facility for most multi–trauma.
2. This is a guideline only. It does not replace clinical judgement.
3. All transfers must be safe and confer clinical benefit to the patient.
4. Notification between senior transferring and accepting medical staff precedes all transfers.
5. These guidelines have been agreed by all involved clinicians and endorsed by the four Northern Region CMOs.
Trauma inter-hospital transfer guidelines for Kaitaia, Dargaville and Bay of Islands Hospitals
Condition
Hospital to refer to
Comment
Traumatic Brain Injury
GCS≥ 13 +/- concussion, not resolving
GCS 9 - 12
GCS <9 and/or open brain injury e.g. compound skull fracture
Whangarei or Starship/Auckland
Whangarei or Starship/Auckland
Starship/Auckland
D/w Whangarei ED SMO on 021 672 512
D/w Whangarei ED SMO on 021 672 512
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Spine
Suspect spinal injury, no motor deficit
Spinal cord injury:
• Isolated with motor deficit
• Multitrauma but not TBI or chest injuries
Spinal cord injury - with other major injuries such as TBI or
chest
Paeds - Starship
Adults - Middlemore
X-ray and d/w Whangarei Orthopaedic team and/or refer to
Whangarei Hospital for further imaging as needed.
Refer to Supra-regional Spinal Cord Injury Guidelines
Paeds - Starship
Adults - Middlemore or Auckland
For adult patients d/w Intensive Care at Middlemore to
determine whether appropriate to transfer to Middlemore,
otherwise transfer to Auckland by calling 0800 4 TRAUMA
Vascular Injuries
Blunt Carotid/Vertebral/Thoracic Aortic Injuries
Starship/Auckland
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Burns/Plastics
Burns > 20% , or less but affects special sites
Middlemore
Refer to Burn Guideline
D/w Burn Service at Middlemore on 09 250 3800, and fax
referral to 09 276 0114
Refer to Burn Guideline
D/w Burn Service at Middlemore if grafting required
D/w Plastic Surgical Registrar at Middlemore on 021 784 057
Burns <20%
Degloving of face or other special sites or extensive / complex
facial lacerations
Maxillo Facial
All Max Fax injury - Paeds
Isolated Max Fax injury - Adults
Middlemore
Max Fax injury with TBI or chest injuries - Adults
Chest
All paediatric chest injuries - serious
Penetrating chest injury - with shock +/- haemodynamic
instability
Auckland
Multiple rib #, flail chest/ sternum injury
Pulmonary contusions/Pneumothorax/Haemathorax
Abdominal Injuries
Paediatric simple abdominal trauma Paediatric complex abdominal trauma Penetrating abdominal Injury Blunt abdominal injury Complex liver injury
Perineal Injury Special limb injuries
Upper limb with major nerve injury, +/- arterial injury
Upper limb with arterial injury (but no nerve injury)
Whangarei
Whangarei
Upper limb - amputation of viable digit (excluding simple
terminalisation) or partial limb amputation
Mangled lower limb with tissue loss
Middlemore
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Lower limb - penetrating injury with major nerve injury +/arterial injury
Lower limb
• penetrating injury with arterial injury (but no nerve injury)
• blunt injury with ischaemia +/- nerve injury
Orthopaedic
Open or complex pelvic # +/- haemodynamic instability
Middlemore
D/w Orthopaedic Service at Whangarei Hospital to determine
whether to transfer to Whangarei or Middlemore
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Two or more long bone #, acetabulum #
Urology
Ruptured kidney or urethral injuries
Whangarei
Starship
Middlemore
Starship
Starship /Auckland
Whangarei
Starship
Whangarei or Auckland
Whangarei
Auckland
Whangarei
Middlemore
Starship / Auckland
D/w Max Fax (021 292 1593) or
Plastic Surgical Registrar (021 784 057) at Middlemore
Adults: Call 0800 4 TRAUMA
If (adult) patient has > 1,500ml blood loss in chest drain,
not responding to resusication, needs urgent thoracotomy.
Transfer when stabilised. Call 0800 4 TRAUMA
If transfer to Auckland required, call 0800 4 TRAUMA
Call 0800 4 TRAUMA
D/w Orthopaedic Service at Whangarei Hospital to determine
whether to transfer to Whangarei or Auckland
Starship/Auckland
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Starship/Whangarei
27
Auckland City Hospital Trauma Team Guidelines | June 2016
Northern Regional Trauma Network
1. These criteria should prompt bypass or immediate transfer to definitive care facilities. Startship (paeds) and
Auckland (adults) is the definitive care facility for most multi–trauma.
2. This is a guideline only. It does not replace clinical judgement.
3. All transfers must be safe and confer clinical benefit to the patient.
4. Notification between senior transferring and accepting medical staff precedes all transfers.
5. These guidelines have been agreed by all involved clinicians and endorsed by the four Northern Region CMOs.
Trauma inter-hospital transfer guidelines for Whangarei Hospital
Condition
Go To
Comment
CT
CT, d/w Neurosurgery at Auckland
GCS <9 and/or open brain injury e.g. compound skull fracture
Whangarei
Whangarei or
Starship/Auckland
Starship/Auckland
Extra axial lesion on CT
Starship/Auckland
Traumatic Brain Injury
GCS≥ 13 +/- concussion, not resolving
GCS 9 - 12
Spine
Suspect spinal injury, no motor deficit
Spinal cord injury:
• Isolated with motor deficit
• Multitrauma but not TBI or chest injuries
Spinal cord injury - with other major injuries such as TBI or
chest
Vascular Injuries
Blunt Carotid/Vertebral/Thoracic Aortic Injuries
Burns/Plastics
Burns > 20% , or less but affects special sites
Whangarei
Paeds - Starship
Adults - Middlemore
Refer to Supra-regional Spinal Cord Injury Guidelines
Paeds - Starship
Adults - Middlemore or Auckland
For adult patients d/w Intensive Care at Middlemore to
determine whether appropriate to transfer to Middlemore,
otherwise transfer to Auckland by calling 0800 4 TRAUMA
Starship/Auckland
Paeds: Call Starship Adults: Call 0800 4 TRAUMA
Middlemore
Refer to Burn Guideline
D/w Burn Service at Middlemore on 09 250 3800,
and fax referral to 09 276 0114
Refer to Burn Guideline
D/w Burn Service at Middlemore if grafting required
D/w Plastic Surgical Registrar at Middlemore on 021 784 057
Burns <20%
28
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Degloving of face or other special sites or extensive / complex
facial lacerations
Maxillo Facial
All Max Fax injury - Paeds
Isolated Max Fax injury - Adults
Middlemore
Max Fax injury with TBI or chest injuries - Adults
Chest
All paediatric chest injuries - serious
Penetrating chest injury - with shock +/- haemodynamic
instability
Multiple rib #, flail chest/ sternum injury
Pulmonary contusions/Pneumothorax/Haemathorax
Abdominal Injuries
Paediatric simple abdominal trauma Paediatric complex abdominal trauma Penetrating abdominal Injury Blunt abdominal injury Complex liver injury – stable
Complex liver injury - unstable, ≥ Grade 3 liver trauma
Perineal Injury Special limb injuries
Upper limb with major nerve injury, +/- arterial injury
Upper limb with arterial injury (but no nerve injury)
Auckland
D/w Max Fax (021 292 1593) or
Plastic Surgical Registrar (021 784 057) at Middlemore
Call 0800 4 TRAUMA
Starship
Adults - Whangarei or Auckland
Paeds: Call Starship
If transfer to Auckland required, call 0800 4 TRAUMA
Whangarei or Auckland
Whangarei
Call 0800 4 TRAUMA
Upper limb - amputation of viable digit (excluding simple
terminalisation) or partial limb amputation
Mangled lower limb with tissue loss
Middlemore
Lower limb - penetrating injury with major nerve injury +/arterial injury
Lower limb
• penetrating injury with arterial injury (but no nerve injury)
• blunt injury with ischaemia +/- nerve injury
Orthopaedic
Open or complex pelvic # +/- haemodynamic instability
Middlemore
Two or more long bone #, acetabulum #
Urology
Ruptured kidney or urethral injuries
Whangarei
Starship
Middlemore
Whangarei
Starship
Whangarei or Auckland
Whangarei
Auckland
Auckland
Whangarei
Middlemore
Starship / Auckland
Middlemore
If transfer to Auckland required, call 0800 4 TRAUMA
Call 0800 4 TRAUMA
Call 0800 4 TRAUMA
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Refer to Mangled Limb Algorithm.
D/w Orthopaedic Registrar at Middlemore on 021 594 764
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Starship / Auckland
If transfer required:
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Starship/Auckland
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Whangarei
Northern Regional Trauma Network
1. These criteria should prompt bypass or immediate transfer to definitive care facilities. Startship (paeds) and
Auckland (adults) is the definitive care facility for most multi–trauma.
2. This is a guideline only. It does not replace clinical judgement.
3. All transfers must be safe and confer clinical benefit to the patient.
4. Notification between senior transferring and accepting medical staff precedes all transfers.
5. These guidelines have been agreed by all involved clinicians and endorsed by the four Northern Region CMOs.
6. At Waitakere Hospital CT imaging with contrast is not available after-hours or weekends. When advanced imaging is not available
the most serious injury should be assumed and the patient transferred directly to the hospital of definitive care. This will most
often be Auckland/Starship.
Trauma inter-hospital transfer guidelines for Waitakere Hospital
Condition
Traumatic Brain Injury
GCS≥ 13 +/- concussion, not resolving
All other TBI with GCS <13, +/- open brain injury, +/- extra
axial lesion on CT
Spine
Suspect spinal injury, no motor deficit
Spinal cord injury:
• Isolated with motor deficit
• Multitrauma but not TBI or chest injuries
Spinal cord injury - with other major injuries such as TBI or
chest
Vascular Injuries
Blunt Carotid/Vertebral/Thoracic Aortic Injuries
Burns/Plastics
Burns > 20% , or less but affects special sites
Burns <20%
Degloving of face or other special sites or extensive /
complex facial lacerations
Maxillo Facial
All Max Fax injury - Paeds
Isolated Max Fax injury - Adults
Go To
Paeds - Starship
Adults - North Shore
Starship/Auckland
Paeds: Call Starship Adults: Call 0800 4 TRAUMA
North Shore
+/- CT
Paeds - Starship
Refer to Supra-regional Spinal Cord Injury Guidelines.
Adults - Middlemore
Paeds - Starship
For adult patients d/w Intensive Care at Middlemore to determine whether
Adults - Middlemore appropriate to transfer to Middlemore, otherwise transfer to Auckland by
or Auckland
calling 0800 4 TRAUMA. See Note 6.
Starship/Auckland
Paeds: Call Starship Adults: Call 0800 4 TRAUMA. See Note 6.
Middlemore
Refer to Burn Guideline
D/w Burn Service at Middlemore on 09 250 3800, and fax referral to 09 276 0114
Refer to Burn Guideline. D/w Burn Service at Middlemore if grafting required
D/w Plastic Surgical Registrar at Middlemore on 021 784 057
Middlemore
Starship
Middlemore
Max Fax injury with TBI or chest injuries - Adults
Chest
All paediatric chest injuries - serious
Penetrating chest injury - with shock +/- haemodynamic
instability
Multiple rib #, flail chest/ sternum injury
Pulmonary contusions/Pneumothorax/Haemathorax
Abdominal Injuries
All paediatric abdominal trauma Penetrating abdominal Injury Blunt abdominal injury Auckland
Complex liver injury - stable or unstable
Perineal Injury Special limb injuries
Upper limb with major nerve injury, +/- arterial injury
Upper limb with arterial injury (but no nerve injury)
Auckland
Auckland
Starship
Auckland
Auckland
Auckland
Starship
Auckland
See comment
Middlemore
Starship / Auckland
Upper limb - amputation of viable digit
Middlemore
(excluding simple terminalisation) or partial limb amputation
Mangled lower limb with tissue loss
Middlemore
Lower limb - penetrating injury with major nerve injury +/arterial injury
Lower limb
• penetrating injury with arterial injury (but no nerve injury)
• blunt injury with ischaemia +/- nerve injury
Orthopaedic
Open or complex pelvic # +/- haemodynamic instability
Two or more long bone #
Acetabulum #
Urology
Ruptured kidney or urethral injuries
Comment
Middlemore
D/w Max Fax (021 292 1593) or Plastic Surgical Registrar (021 784 057) at
Middlemore
Call 0800 4 TRAUMA
Call 0800 4 TRAUMA. Consider need for resuscitative thoracotomy in ED to
stabilise prior to transfer.
If minor - North Shore.
If severe - Auckland. See Note 6.
See Note 6
Call 0800 4 TRAUMA
Default hospital is Auckland - all 0800 4 TRAUMA. See Note 6.
If definitive imaging is available and no solid organ injury and clinically stable,
then transfer to North Shore.
Call 0800 4 TRAUMA
Call 0800 4 TRAUMA
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Refer to Mangled Limb Algorithm.
D/w Orthopaedic Registrar at Middlemore on 021 594 764
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Starship / Auckland
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Starship/Auckland
Paeds - Starship
Adults - see
comment
North Shore
Paeds: Call Starship Adults: Call 0800 4 TRAUMA
Paeds : Call Starship Adults: Default hospital is Auckland. Call 0800 4 TRAUMA.
If definitive imaging is available and no multi-system injury and stable, then
transfer to North Shore. See Note 6
D/w on-call Orthoaedic Consultant prior to transfer. See Note 6
Starship/Auckland
Paeds: Call Starship Adults: Call 0800 4 TRAUMA. See Note 6.
29
Auckland City Hospital Trauma Team Guidelines | June 2016
Northern Regional Trauma Network
1. These criteria should prompt bypass or immediate transfer to definitive care facilities. Startship (paeds) and
Auckland (adults) is the definitive care facility for most multi–trauma.
2. This is a guideline only. It does not replace clinical judgement.
3. All transfers must be safe and confer clinical benefit to the patient.
4. Notification between senior transferring and accepting medical staff precedes all transfers.
5. These guidelines have been agreed by all involved clinicians and endorsed by the four Northern Region CMOs.
Trauma inter-hospital transfer guidelines for North Shore Hospital
Condition
Traumatic Brain Injury
GCS≥ 13 +/- concussion, not resolving
All other TBI with GCS <13, +/- open brain injury, +/- extra
axial lesion on CT
Spine
Suspect spinal injury, no motor deficit
Spinal cord injury:
• Isolated with motor deficit
• Multitrauma but not TBI or chest injuries
Spinal cord injury - with other major injuries such as TBI or
chest
Go To
Comment
North Shore
Starship/Auckland
CT
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
North Shore
Paeds - Starship
Adults - Middlemore
Paeds - Starship
Adults - Middlemore or Auckland
For adult patients d/w Intensive Care at Middlemore to
determine whether appropriate to transfer to Middlemore,
otherwise transfer to Auckland by calling 0800 4 TRAUMA
Vascular Injuries
Blunt Carotid/Vertebral/Thoracic Aortic Injuries
Starship/Auckland
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Burns/Plastics
Burns > 20% , or less but affects special sites
Middlemore
Refer to Burn Guideline
D/w Burn Service at Middlemore on 09 250 3800,
and fax referral to 09 276 0114
Refer to Burn Guideline
D/w Burn Service at Middlemore if grafting required
D/w Plastic Surgical Registrar at Middlemore on 021 784 057
Burns <20%
30
Refer to Supra-regional Spinal Cord Injury Guidelines
Degloving of face or other special sites or extensive / complex
facial lacerations
Maxillo Facial
All Max Fax injury - Paeds
Isolated Max Fax injury - Adults
Middlemore
Max Fax injury with TBI or chest injuries - Adults
Chest
All paediatric chest injuries - serious
Penetrating chest injury - with shock +/- haemodynamic
instability
Multiple rib #, flail chest/ sternum injury
Auckland
Pulmonary contusions/Pneumothorax/Haemathorax
Abdominal Injuries
All paediatric abdominal injuries
Penetrating abdominal Injury Blunt abdominal injury All complex liver injuries
Perineal Injury Special limb injuries
Upper limb with major nerve injury, +/- arterial injury
Upper limb with arterial injury (but no nerve injury)
North Shore
Upper limb - amputation of viable digit
(excluding simple terminalisation) or partial limb amputation
Mangled lower limb with tissue loss
Middlemore
Lower limb - penetrating injury with major nerve injury +/arterial injury
Lower limb
• penetrating injury with arterial injury (but no nerve injury)
• blunt injury with ischaemia +/- nerve injury
Orthopaedic
Open or complex pelvic # +/- haemodynamic instability
Middlemore
Starship
Middlemore
Starship
Auckland
North Shore or Auckland
Starship
Auckland
North Shore
Auckland
Auckland
Middlemore
Starship / Auckland
Middlemore
D/w Max Fax (021 292 1593) or
Plastic Surgical Registrar (021 784 057) at Middlemore
Call 0800 4 TRAUMA
Call 0800 4 TRAUMA
Consider need for resuscitative thoracotomy prior to transfer
If minor - North Shore.
If severe - Auckland, by calling 0800 4 TRAUMA
Call 0800 4 TRAUMA
Call 0800 4 TRAUMA
Call 0800 4 TRAUMA
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Refer to Mangled Limb Algorithm.
D/w Orthopaedic Registrar at Middlemore on 021 594 764
Call Plastic Surgical Registrar at Middlemore on 021 784 057
Starship / Auckland
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Starship/Auckland
Paeds: Call Starship
Adults: Call 0800 4 TRAUMA
Paeds : Call Starship
Adults: If no multi-system injury and stable manage at North
Shore. Otherwise transfer to Auckland. Call 0800 4 TRAUMA.
Two or more long bone #
Paeds: Starship
Adults: see comment
Acetabulum #
Urology
Ruptured kidney or urethral injuries
North Shore
Starship/Auckland
Call 0800 4 TRAUMA
Northern Regional Trauma Network
1. These criteria should prompt bypass or immediate transfer to definitive care facilities. Startship (paeds) and
Auckland (adults) is the definitive care facility for most multi–trauma.
2. This is a guideline only. It does not replace clinical judgement.
3. All transfers must be safe and confer clinical benefit to the patient.
4. Notification between senior transferring and accepting medical staff precedes all transfers.
5. These guidelines have been agreed by all involved clinicians and endorsed by the four Northern Region CMOs.
Trauma inter-hospital transfer guidelines for Middlemore Hospital
Condition
Traumatic Brain Injury
GCS≥ 13 +/- concussion, not resolving
GCS 9 - 12
GCS <9 and/or open brain injury e.g. compound skull fracture
Extra axial lesion on CT
Spine
Suspect spinal injury, no motor deficit
Spinal cord injury:
• Isolated with motor deficit
• Multitrauma but not TBI or chest injuries
Spinal cord injury - with other major injuries such as TBI or
chest
Vascular Injuries
Blunt Carotid/Vertebral/Thoracic Aortic Injuries
Burns/Plastics
Burns > 20% , or less but affects special sites
Burns <20%
Degloving of face or other special sites or extensive / complex
facial lacerations
Maxillo Facial
All Max Fax injury - Paeds
Isolated Max Fax injury - Adults
Max Fax injury with TBI or chest injuries - Adults
Chest
All paediatric chest injuries - serious
Penetrating chest injury - with shock +/- haemodynamic
instability
Multiple rib #, flail chest/ sternum injury
Pulmonary contusions/Pneumothorax/Haemathorax
Abdominal Injuries
Paediatric simple abdominal trauma Paediatric complex abdominal trauma Penetrating abdominal Injury Blunt abdominal injury Complex liver injury – stable
Complex liver injury - unstable, ≥ Grade 3 liver trauma
Perineal Injury Special limb injuries
Upper limb with major nerve injury, +/- arterial injury
Upper limb with arterial injury (but no nerve injury)
Upper limb - amputation of viable digit
(excluding simple terminalisation) or partial limb amputation
Mangled lower limb with tissue loss
Lower limb - penetrating injury with major nerve injury +/arterial injury
Lower limb
• penetrating injury with arterial injury (but no nerve injury)
• blunt injury with ischaemia +/- nerve injury
Orthopaedic
Open or complex pelvic # +/- haemodynamic instability
Two or more long bone #
Acetabulum #
Urology
Ruptured kidney
Urethral injuries
Go To
Regional
referral centre
P = Paeds
A = Adults
Middlemore
Middlemore
Paeds - Starship
Adults - Middlemore
Comment
CT, d/w Neurosurgeons at Auckland, if transfer required call:
* Paeds call Starship
* Adults call 0800 4 TRAUMA
A
Paeds - Starship
Adults - Middlemore
Refer to Supra-regional Spinal Cord Injury Guidelines
Paeds: all paeds go to Starship
Adults: determine if appropriate to keep or refer to Auckland
for tertiary services. Call 0800 4 TRAUMA
There is a 24*7 Vascular Service at Middlemore. All vascular injuries should be discussed with that
service first. The Vascular Consultant will give clear advice on whether to transfer the patient to
Auckland and to which service the patient should be referred.
Discuss with
May require transfer to Auckland. If transfer required, for
Middlemore
Paeds call Starship, for Adults call 0800 4 TRAUMA
Vascular Consultant.
Middlemore
Middlemore
Middlemore
P/A
P/A
Starship
Middlemore
Middlemore
D/w Plastic Surgical Registrar at Middlemore on 021 784 057
A
Starship
Middlemore
Isolated Paediatric Max Fax Injury may be managed at
Middlemore. D/w Max Fax or Plastics Registrar
Determine if appropriate to keep or refer to Auckland for
tertiary services. Call 0800 4 TRAUMA
Determine if appropriate to keep or refer to Auckland for
tertiary services. Call 0800 4 TRAUMA
Middlemore
Middlemore
Starship
Starship
Middlemore
Middlemore
Middlemore
Middlemore
Determine if appropriate to keep or refer to Auckland for
tertiary services. Call 0800 4 TRAUMA
Middlemore
Middlemore
Middlemore
Middlemore
P/A
Middlemore
Middlemore
P/A
P/A
P/A
Middlemore
Paeds - Starship
Adults - Middlemore
Paeds - Starship
Adults - Middlemore
Middlemore
Paeds - Starship
Adults - Middlemore
Paeds - Starship
Adults - Auckland
Determine if appropriate to keep or refer to Auckland for
tertiary services. Call 0800 4 TRAUMA
Discuss with Urology Registrar at Auckland
31
Auckland City Hospital Trauma Team Guidelines | June 2016
Appendices
Appendix A: Ambulance Triage Codes
Ambulance condition status codes:
Status 1
Critical
Extreme
Status 2
Serious
Status 3
Moderate
Status 4
Patient condition
Stability
Unstable
Unstable
Stable
Stable
Obvious
Probable
Unlikely
None
Under CPR
GCS<9
Airway obstr.
Uncontrolled
haemorrhage
Not under CPR
GCS<9
Potential to deteriorate
Special criteria
Assist. Resps.
Syst. BP<90
P>130 or <50
32
Minor
Status Zero
Dead
Appendix B: Techniques; FAST, DA, DPL
FAST scan
1.
The Hepatorenal pouch (of Morison). This is the RUQ scan and should be done first, as it is the most sensitive for fluid identification. If it is positive there is no need to go on to the other four quadrants unless a pericardial effusion is suspected.
2.
The Subphrenic/Splenic Recess. This can be the hardest scan to do and is looking for fluid between the spleen and L)
kidney.
3.
The Suprapubic Region. This looks for fluid in the pelvis. This scan can be misleading, as fluid tracking from a pelvic fracture
may be present. Also in women there may be fluid present in the pouch of Douglas that could be physiological.
4.
The Sub-Xiphisternal/Pericardial View. This can be useful for both blunt and penetrating trauma in identification of pericardial
tamponade.
DPL technique
1.
Ensure that the patient has a gastric tube and urinary catheter in place
2.
Prep the abdomen with Betadine and drape the umbilical region.
3.
Inject local anaesthetic with adrenaline in the midline subumbilical region (supraumbilical if pelvic fracture present).
4.
Vertically incise the skin and subcutaneous tissue down to the fascia.
5.
Insert a small self-retaining retractor to hold the tissues open and stop any bleeding.
6.
Incise the fascia and identify the peritoneum. Insert a purse-string suture to stop leakage of lavage fluid.
7.
Make a small hole in the peritoneum and insert the lavage catheter, directing it into the pelvis.
8.
Connect the catheter to a syringe and aspirate.
9.
If < 10mls of frank blood is aspirated instil 1 litre of warmed crystalloid and agitate the abdomen gently.
10. Allow the fluid to siphon off. At least 250mls must be removed for the lavage result to be representative.
11. Remove the catheter and suture the fascia and skin.
33
Appendix C: Auckland City Hospital Major Trauma Form
Auckland City Hospital Trauma Team Guidelines | June 2016
34
35
Auckland City Hospital Trauma Team Guidelines | June 2016
36
37